The Choice To Rebuild Your Breasts After A Mastectomy Is Yours
Knowing your insurance rights can help with your decision.
Under state and federal law , if your insurance company covers mastectomies, it must also cover related services, including reconstructive surgery and breast prostheses or forms if you don’t select surgery. This is true even if the mastectomy is not due to a cancer diagnosis and even if your surgery is delayed. Coverage must include:
- All stages of reconstruction of the breast on which the mastectomy has been performed.
- Surgery and reconstruction of the other breast to produce a symmetrical or balanced appearance.
- Any external prostheses that fit into your bra before or during the reconstruction.
- Treatment of physical complications of all stages of the mastectomy, including lymphedema or fluid build-up in the arm or chest.
- Any medically necessary hospitalization for treatment.
Your insurer must notify you of this coverage when you enroll and every year after.
Using Your Own Tissue
Reconstruction using your own skin, fat and muscle is called tissue flap reconstruction. There are two main types of tissue flap reconstruction. These are attached flaps and free flaps.
- Attached flaps use skin, fat and muscle from your back or abdomen. A portion of tissue and muscle is tunnelled under the skin from your back or abdomen to your chest where the new breast is formed.
- Free flaps use skin, fat and muscle removed from your abdomen or buttock. The arteries and veins are cut and then attached to the blood supply of the chest wall.
The main advantages of tissue flap reconstruction are:
- it produces a more natural looking breast
- the breast will gain and lose weight as your body gains and loses weight.
The main disadvantages of tissue flap reconstruction are:
- it requires longer surgery and recovery time
- you will have a scar on your back or stomach
- you may lose strength in your stomach muscles if your reconstruction uses abdominal tissue
- there is a small risk that the flap may die due to lack of blood supply if this happens it may need to be removed and another operation may be required.
Are Cancer Drugs Covered By Medicare
For chemotherapy and other cancer-related drugs and supplies, your Medicare prescription drug plan may cover it.
Medicare.gov explains Part D covers most prescription medications and some chemotherapy treatments and drugs. If Part B doesnât cover a cancer drug, your Part D prescription drug plan may cover it.
Please be sure to check with your plan to make sure your drugs are on the planâs formulary .
The following cancer drugs may be covered by your Medicare Part D drug plan:
- Prescription drugs for chemotherapy only available to be taken by mouth
- Anti-nausea drugs
- Other prescription drugs used in the course of your cancer treatment, like pain medication
Remember that Medicare Part B isnât 100% coverage. You will still have a 20% coinsurance as well as a deductible. Be sure to consider a Medicare Supplement to pick up those costs.
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Facial Surgery Procedures Eye / Ear
42590 Canthoplasty, medial or lateral
45617 Upper eyelid, reduction of, if: the reduction is for any of the following: skin redundancy that causes a visual field defect or intertriginous inflammation of the eyelid herniation of orbital fat in exophthalmos facial nerve palsy post-traumatic scarring the restoration of symmetry of contralateral upper eyelid in respect of one of the conditions mentioned in subparagraphs to and photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes
45659 Correction of a congenital deformity of the ear if: the patient is less than 18 years of age and the deformity is characterised by an absence of the antihelical fold and/or large scapha and/or large concha and photographic evidence demonstrating the clinical need for this service is documented in the patient notes
When Will Medicare Cover Plastic Surgery
Plastic surgery and cosmetic surgery are often used interchangeably. However, there are some fundamental differences between the two types of surgeries.
Reconstructive plastic surgery is used to repair areas of the body that may be affected by trauma, disease, or developmental defects. Cosmetic plastic surgery is a type of plastic surgery that is used to enhance the natural features of the body.
Due to the distinctions between these two types of surgeries, there are differences in the education, training, and certification of plastic and cosmetic surgeons:
- Plastic surgeons are certified by the American Board of Plastic Surgery. After medical school, they must undergo at least six years of surgical training and three years of residency training. They must pass a series of exams and take part in continuing education programs each year. Board-certified plastic surgeons only perform surgery in accredited or licensed facilities.
- Cosmetic surgeons must have at least four years of residency experience to become certified by the American Board of Medical Specialties. After this, they can choose to become certified by the American Board of Cosmetic Surgery. However, this is not a requirement.
Many board-certified plastic surgeons also practice cosmetic surgery. To practice both, plastics surgeons must have additional training in cosmetic surgery.
If you are enrolled in Medicare, there are three primary situations when Medicare will cover your plastic surgery.
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Does Medicare Cover Rhinoplasty
Medicare will only cover rhinoplasty surgery if its need stems from a mishap or, if the surgery improves bodily function. Rhinoplasty surgery fixes the septal bone.
Those that have septum deviation along with a large, misshapen, bent nose may have insurance pay a portion of costs. If you want the surgery for image goals, coverage wont be likely.
Medicare covers when functional issues are present. Many people mix rhinoplasty with other nose surgeries.
For example, a broken nose can have repair from an open reduction nasal fracture. Also, a septoplasty can solve breathing issues.
If youre having problems with your nose, talk to your doctor about the best choice for you.
Personal Stories About Breast Reconstruction After Mastectomy
These stories are based on information gathered from health professionals and consumers. They may be helpful as you make important health decisions.
I kind of went into shock when my doctor told me I had breast cancer and would need to have my right breast removed. I started listening again when she described how I could have my breast reshaped. Knowing I could have this done right away before I even woke up from the mastectomy made the whole thing easier to deal with. I chose to have DIEP flap surgery, using tissue from my belly. I knew it would take awhile to heal and look like a breast, and I did have to have surgery on my left breast to help them match. But I am so glad I did it. It has helped me feel stronger after the trauma of cancer.
Claudia, age 42
When my doctor first mentioned that I could have my breast rebuilt after the mastectomy, I was kind of interested. I didn’t know they could do things like that, taking tissue from your back or belly. But the more I thought about it, the more it didn’t feel right for me. It seemed like a distraction when all I wanted to focus on was beating the cancer and getting back to my life. I talked to my husband about it, and he totally supported my decision. Maybe sometime down the road I might change my mind. But for now I use a prosthesis in my bra, and this works fine.
Patrice, age 51
Jewel, age 73
Kerry-Ann, age 45
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Does Medicare Cover Breast Reconstruction Surgery
If you have had a mastectomy, or are about to have one, you arent alone. In 2020 in the United States, over a quarter-million women were diagnosed with invasive breast cancer. And typically, over 100,000 women have a mastectomy of some type every year. Not all mastectomies are due to a breast cancer diagnosis, some are performed as a pro-active measure to lower the risk of getting breast cancer.
Medicare Benefits Solutions
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Statistics show that the greatest risk factor for getting breast cancer is age. In fact, 50 percent of new cases generally occur in women between 50 and 69 years old. That risk is even higher when women are between 60 and 70 years of age.
Whether youve had a mastectomy or are preparing for one, your physician may have discussed your options for breast reconstruction surgery. Reconstruction surgery can be done during your mastectomy procedure or after even months or years later.
How your Medicare insurance covers breast reconstruction surgeryIf you have coverage through Original Medicare Part A and Medicare Part B , or through a Medicare Advantage plan, you have coverage for surgical procedures that are deemed medically necessary.
If you are enrolled in a Medicare Advantage plan, you will have at least the same coverage as Original Medicare Part A and Part B, but many MA plans include additional benefits.
Breast Surgery Mbs Item Numbers
- 45060 Breast Asymmetry or Tubular Breast surgery
- 45520 Breast Reduction Surgery Unilateral
- 45523 Breast Reduction Surgery Bilateral
- 45548 Removal of Breast Implant
- 45551 Breast Implant Removal with Capsulectomy
- 45553 Remove and Replace Breast Implants due to a complication
- 45554 Remove and Replace Breast implants due to a complication
- 45558 Breast Lift / Mastopexy
- 31519 Mastectomy / Total Removal of Breasts
- 31525 Mastectomy for Gynecomastia excision of Breast Tissue
- 31563 Inverted Nipple Correction
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What To Expect Before And After Surgery
A mastectomy is a major surgery that will require preparation, at least several days in the hospital, and an extensive recovery process. The type of cancer you have may also require systemic treatments or radiation therapy. Even prophylactic surgeries have long-term impact, both physically and emotionally.
Does Medicare Cover A Mastectomy
There are over three million women in the United States with a history of breast cancer, and 12 percent of all women in the country are at risk of developing breast cancer at some time in their lives. The risk is lower for men, but 1 out of every 883 men in the U.S. is diagnosed with breast cancer.
Fortunately, the number of deaths due to breast cancer have been steadily declining since 1989. This is due to a heightened awareness, early detection, and advances in treatment. Although breast cancer is the primary reason for having mastectomies, they are also an option for people who have severe, chronic breast pain, fibrocystic breast disease, or a family history of breast cancer.
If you are faced with the possibility of a mastectomy you should know the facts about your Medicare coverage and what to expect from surgery.
What is a Mastectomy?A mastectomy is either the partial or complete removal of one or both breasts, done surgically. There are different types of mastectomy that are performed for different conditions. The most common types are:
Total, or simple mastectomy which involves removal of the entire breastwithout removing the muscles underneath. Double, or bilateral mastectomy includes removal of both breasts. Radical mastectomy includes removal of breast, lymph nodes from underarm, and chest wall muscles. Modified radical mastectomy is the same as radical but the chest wallmuscles are not removed.
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What Are Other Situations Where Medicare May Cover Breast Implants
- Medicare may cover breast implants as part of a sex reassignment surgery on a case by case basis if you are at least 18 years old and have a documented case of gender dysphoria. According to the American Psychiatric Association, gender dysphoria involves a conflict between a persons physical or assigned gender and the gender with which they identify.
- Medicare generally does not cover breast implants as part of a cosmetic procedure not related to a mastectomy or sex reassignment surgery. Typically, Medicare does not cover cosmetic procedures unless they are part of an accidental injury or are to improve a malformed part of the body.
- Medicare usually does not cover breast implant removal unless it qualifies as a covered cosmetic surgery.
Medicaid Coverage For Breast Reconstruction Surgery
The WHCRA of 1998 does not include the federal Medicaid program. Medicaid provides health insurance coverage to individuals and families with low income and no access to other resources. Each state is free to decide whether it includes breast reconstructive surgery as a covered benefit. to go to the Medicaid website for West Virginia.
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How Far Along Your Breast Cancer Is Will Greatly Impact Your Costs
What will have the greatest impact on overall medical costs is how far along the breast cancer has progressed.
A 2016 study completed by Helen Blumen, Kathryn Fitch, and Vincent Polkus examined the costs of care depending on which stage the breast cancer was when diagnosed.
This study found that overall, treatment costs were higher for patients whose cancer was more advanced when they were diagnosed. This is largely due to chemotherapy, which was responsible for the highest percentage of total costs for stage 4 patients.
In the second year after being diagnosed, chemo costs were the single largest contributor to treatment costs in every single stage of the disease.
However, for patients who were diagnosed early on , their surgery costs were more than double those with stage 4 breast cancer, which reflects the curative nature of surgery for early-stage disease.
When looking at the average costs per patient allowed by the insurance company in this study, the expenses range from $60,000-$134,000 depending on how advanced the breast cancer was at diagnosis.
Those numbers can be striking, so itâs important to know: does Medicare cover breast cancer?
Does Medicaid Cover Plastic Surgery
Many beneficiaries have both Medicare and Medicaid. In this case, Medicaid is a state plan and each state will cover differently. People in some states will have benefits from both programs, others may only receive help through Medicare.
To have coverage, documentation is vital. Records show proof of medical need. If your procedure isnt a definite need, expect a claim denial. Talk to your insurance about company-specific rules prior to surgery.
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Women’s Health And Cancer Rights Act
The Women’s Health and Cancer Rights Act of 1998 is a federal law that provides protections to patients who choose to have breast reconstruction in connection with a mastectomy.
If WHCRA applies to you and you are receiving benefits in connection with a mastectomy and you elect breast reconstruction, coverage must be provided for:
- All stages of reconstruction of the breast on which the mastectomy has been performed
- Surgery and reconstruction of the other breast to produce a symmetrical appearance and
- Prostheses and treatment of physical complications of all stages of the mastectomy, including lymphedema.
This law applies to two different types of coverage:
Group health plans can either be insured plans that purchase health insurance from a health insurance issuer, or self-funded plans that pay for coverage directly. How they are regulated depends on whether they are sponsored by private employers, or state or local governmental employers. Private group health plans are regulated by the Department of Labor. State and local governmental plans, for purposes of WHCRA, are regulated by CMS. If any group health plan buys insurance, the insurance itself is regulated by the States insurance department.
Contact your employers plan administrator to find out if your group coverage is insured or self-funded, to determine what entity or entities regulate your benefits.
What Factors Can Affect The Timing Of Breast Reconstruction
One factor that can affect the timing of breast reconstruction is whether a woman will need radiation therapy. Radiation therapy can sometimes cause wound healing problems or infections in reconstructed breasts, so some women may prefer to delay reconstruction until after radiation therapy is completed. However, because of improvements in surgical and radiation techniques, immediate reconstruction with an implant is usually still an option for women who will need radiation therapy. Autologous tissue breast reconstruction is usually reserved for after radiation therapy, so that the breast and chest wall tissue damaged by radiation can be replaced with healthy tissue from elsewhere in the body.
Another factor is the type of breast cancer. Women with inflammatory breast cancer usually require more extensive skin removal. This can make immediate reconstruction more challenging, so it may be recommended that reconstruction be delayed until after completion of adjuvant therapy.
Even if a woman is a candidate for immediate reconstruction, she may choose delayed reconstruction. For instance, some women prefer not to consider what type of reconstruction to have until after they have recovered from their mastectomy and subsequent adjuvant treatment. Women who delay reconstruction can use external breast prostheses, or breast forms, to give the appearance of breasts.
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What Are Some New Developments In Breast Reconstruction After Mastectomy
Oncoplastic surgery. In general, women who have lumpectomy or partial mastectomy for early-stage breast cancer do not have reconstruction. However, for some of these women the surgeon may use plastic surgery techniques to reshape the breast at the time of cancer surgery. This type of breast-conserving surgery, called oncoplastic surgery, may use local tissue rearrangement, reconstruction through breast reduction surgery, or transfer of tissue flaps. Long-term outcomes of this type of surgery are comparable to those for standard breast-conserving surgery .
Autologous fat grafting. A newer type of breast reconstruction technique involves the transfer of fat tissue from one part of the body to the reconstructed breast. The fat tissue is harvested by liposuction, washed, and liquified so that it can be injected into the area of interest. Fat grafting is mainly used to correct deformities and asymmetries that may appear after breast reconstruction. It is also sometimes used to reconstruct an entire breast. Although concern has been raised about the lack of long-term outcome studies, this technique is considered safe .
Selected References
1. Mehrara BJ, Ho AY. Breast Reconstruction. In: Harris JR, Lippman ME, Morrow M, Osborne CK, eds. Diseases of the Breast. 5th ed. Philadelphia: Wolters Kluwer Health 2014.
2. Cordeiro PG. Breast reconstruction after surgery for breast cancer. New England Journal of Medicine 2008 359:15901601. DOI: 10.1056/NEJMct0802899